Factors Related to the Occurrence of Diarrheal Disease in Under-Five Children of IDP s in Bosaso, Puntland-Somalia

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1 World Journal of Medical Sciences 13 (1): 54-59, 2016 ISSN IDOSI Publications, 2016 DOI: /idosi.wjms Factors Related to the Occurrence of Diarrheal Disease in Under-Five Children of IDP s in Bosaso, Puntland-Somalia 1,2,3 1, Mohamed Kalid, Elmi Omar, Abdikarin A. Ibrahim, Shukri A. Said and Deko A. Farah 1 Department of Public Health and Nutrition East Africa University, Bosaso-Puntland, Somalia 2 Citizen College of Health, East Africa University, Bosaso-Puntland, Somalia 3 Center of Research Training and Development East Africa University, Bosaso-Puntland, Somalia Abstract: Globally about 4 million cases of diarrhea are recorded annually and this causes about 2.2 million deaths, mostly among children under the age five. About 50% of deaths are due to acute watery stool, 35% are due to persistent diarrhea and 15% are due to dysentery. A cross-sectional descriptive study was conducted in Bosaso, Puntland, Somalia to identify the factors (socio-demographic characteristics of caregivers, child characteristics, environmental and sanitation factors) related to the occurrence of diarrheal disease in under-five children in Bosaso district IDPs, Somalia. Data of 245 caregivers of the under-five children were collected from four IDPs, during the summer season (June-July, 2015). Data were collected by structured questionnaire and face-to-face interviews in all IDPs. Odds ratio was used to identify factors related to the occurrence of diarrheal disease. Most caregivers reported no diarrhea in their children in the month prior to the day of the interview, 7.34% reported one episode and only 2.85% reported two episodes and 0.4% reported 3 times. 89.7% had watery type of diarrhea. Diarrhea also occurred more often in children who were not exclusively breastfed. However, there was statistically significant association (O.R.= ). The other factors that were statistically significant associated with the occurrence of diarrheal disease included: unhygienic drinking water storage (O.R.= ) and unhygienic homes (O.R = ). Clean Storage of drinking water and hygienic drainage system should be encouraged to all caregivers. Exclusive breastfeeding should be encouraged for prevention of diarrhea for all infants. Key words: Caregivers Children Bosaso Sanitation Diarrhea and IDP INTRODUCTION health burdens among infants and young children in low income countries [5]. An incidence of 3.2 episodes of Diarrhea is a major public health problem especially diarrhea per child per year among children below five in developing countries where it is a leading cause of years old was estimated between 1990 and 2000 within 20 childhood morbidity and mortality [1]. Diarrhea becomes countries [6]. The immediate impact of diarrheal infant the major burden of all water and sanitation related diseases in terms of morbidity, hospitalization and death diseases. Globally about 4 million cases of diarrhea are has been proved in several studies [3]. recorded annually and this causes about 2.2 million In developing countries, diarrheal diseases represent deaths, mostly among children under the age five [2]. one third of the hospitalizations [6]. Children who were About 50% of deaths are due to acute watery stool, 35% not looked after by their mothers and those were partially are due to persistent diarrhea and 15% are due to breastfed or weaned children are at risk for diarrheal dysentery [3]. According to WHO, in developing morbidity [7]. The long term consequence is under countries, diarrhea is the major cause for child death when nutrition when episodes are repeated and prolonged [8] children are less than five years old [4]. Diarrhea mortality Poor socio economic status, sanitation and living is mainly due to dehydration which is the first direct conditions, nutrition and hygiene behavior are the health consequence [3]. Diarrhea morbidity is one of the major determinants for diarrhea prevalence [7]. Corresponding Author: Mohamed Kalid Ali, Faculty of Health Sciences, East Africa University, Bosaso, Somalia. 54

2 In Africa and especially Sub-Saharan Africa, diarrheal 4 IDPs were selected from 34 IDPs by systemic diseases account for over 90% of deaths in children below sampling. After getting approval the questionnaires were five years old [9]. This has been attributed to lack of safe pre-tested for reliability by selecting 30 caregivers from drinking water, sanitation and hygiene as well as poor Tawakal IDP in Bosaso. sample of 245 was collected nutrition [10]. Accordingly, improved water sources through the structured questionnaire in Somali language, reduce diarrhea morbidity by 21%, improved sanitation by by face to face interview, from June to July, % and hand washing by as much as 35% [11]. The sample size were determined by using this WHO/UNICEF, 2006 further observes that the regions formula: with the lowest coverage of improved sanitation in 2006 The sample size will be 245 and will determine the were Sub-Saharan Africa (31%), Southern Asia (33%) and formula below: Eastern Asia (65%) [12]. In Somalia the first major outbreak of cholera in 2 2 N = Z x(p) x(1-p)/d Somalia occurred in 1971 with Vibrio cholerae 01, biotype 2 2 N = (1.96) x(0.2)x(1-0.2)/(0.05) El Tor, serotype Ogawa. A second major outbreak in 1985 N = / N = 245 caused 6300 cases and 1150 deaths affecting Ethiopian refugee camps in Gannet, Hargeisa. In 2007, close to 8000 where cases of acute watery diarrhoea were reported from N= desired Sample size Z = 1.96, the factor from normal Central and Southern Somalia over January to March. In distribution 2011 number of reported cases of cholera in Somalia were P = estimated period of prevalence D = absolute sampling It was the highest cases cases detected forever in error. Somalia (WHO) [12]. In Bosaso, 2011 was occurred about 5352 cases of all Mothers or caregivers having under five children in types of diarrheal diseases, 79% of these cases were selected IDPs were interviewed. A structured occurred on children under the age of 5 years. In 2012, questionnaire were used to collect data and it consisted about 6518 cases of all types of diarrheal diseases of four parts, namely; socio-demographic factors, child occurred, 84% of these cases were occurred on children factors and environment and sanitation factors. under the age of 5 years. In 2013, about 7632 cases of all Descriptive statistics were used to calculate types of diarrheal diseases occurred, 87% of these frequency, percentage, mean, median, maximum, minimum, cases were occurred on children under the age of 5 years. quartile deviation and standard deviation of the In 2014, about 8183 cases of all types of diarrheal diseases independent and dependent variables. occurred, 88% of these cases were occurred on children Crude odds ratio was used to show the strength of under the age of 5 years. In 2015, the first 3 months from association with 95% confidence interval. January to March, about 2000 cases of all types of diarrheal diseases, 82% of these cases were occurred on RESULTS children under the age of 5 years [13]. This shows that children under the age of 5 years are the most vulnerable Socio-Demographic characteristics of Caregivers: The group to these diseases. socio-demographic characteristics of caregivers included The aim of this study was to determine factors that their age, gender, relation to the child, education, influence the occurrence of diarrheal diseases among occupation, family income and time given for the child under five children in Bosaso IDPs. Thus, this study will care. help the ministry of health, Somalia, Health Organizations Almost half (49.4%) of the caregivers were of and policymakers for intervention studies. age between years. Mostly caregivers were female (98%) only (2%) were male caregivers and (90.6%) MATERIALS AND METHODS were mothers. Mostly (69.4%) of the caregivers were illiterate, (3.7%) finished secondary or higher secondary Analytical cross-sectional study was conducted to education (7-12) and only (26.9%) were primary level. identify factors related to the occurrence of diarrheal Most of the caregivers were housewives about (75.5%), disease in children under the age of five years, in the IDPs (15.9%) were employee and the rest (8.6%) were self of Bosaso district of Somalia. employed. 55

3 Table 1: child characteristics (n=245) Variable Frequency Percentage Age Group Less than 1 year % % % % Milk of first six months Breast milk only % Others % Diarrhea during past one month Yes 26 11% No % Episodes of diarrhea in the past one month 1 time % 2-3 times 7 2.9% >3 times 1 0.4% Types of Diarrhea Acute watery Diarrhea 22 85% Bloody Diarrhea 4 15% Majority (58.8%) belonged to the middle income those who are house wives who give enough time for group, (36.7%) were low income group and 4.5% were caring their children. Children of caregivers with low approximately high income group. The majority of the income less than $100 up to $150 dollar had more cases of caregivers (46%) spent 8-15 hrs to take care of their diarrhea and they were times in the risks of having children. diarrhea compare to those with enough income per month from $150 up to $250 or more. Children of caregivers who Child Characteristics: The child characteristics included care their children less than 8 hours had more cases of age of the child in months, milk during first six months of diarrhea and they were times in the risks of having life, diarrhea during the past one month, episodes of diarrhea compare to those who care their children more diarrhea in one month and types of diarrhea. than 8 hours. Table 1 shows that age of most children (54.7%) were Less than 1 year. Exclusive breastfeeding received by Relationship Between Child Factors and Diarrhea approximately half (35.5%) of the children, whereas more Occurrences: As indicated in Table 3, Children in the age than half (64.5%) had received breast milk and others such group between 1-2 years had more diarrhea and they were as powdered milk during first six months of life. There was times in the risk of having diarrhea compared to considerable prevalence (11%) of diarrhea, one episode of other age groups. Children who received others milk diarrhea in majority (7.3%) with mostly (85%) of watery during the first six months of life (not-exclusive) had more type of diarrhea. diarrhea cases with a risk of having diarrhea times more than exclusively breastfed children. Relationship Between the Socio-Demographic Factors of Similarly Children who didn t receive colostrums milk Caregivers and Occurrence of Diarrhea: As shown in had more diarrhea cases with a risk of having diarrhea Table 2, children of caregivers with the age between times more than those who feed colostrums. were in the risks of having diarrhea times compared to those of the caregivers with other ages, Children of Relationship Between Environmental and Sanitation their caregivers are males were times in the risks of Factors and Diarrheal Disease Occurrence: As shown having diarrhea compare to those of female caregivers, in Table 4, Children living in unhygienic conditions had Children of their caregivers are others not their mothers more cases of diarrhea with a risk of having diarrhea were times in the risks of having diarrhea compared times more than compared to those living in to those of mother caregivers. Children of caregivers who hygienic conditions. those who have no latrines had more are illiterate had more cases of diarrhea and they were diarrhea cases with a risk of having diarrhea times times in the risks of having diarrhea compare to more than compared to those having latrines. Similarly those who are literate. Children of caregivers who are those who have no separated drinking water storage had workers or employers who do not give enough time of more diarrhea cases with a risk of having diarrhea caring their children had more cases of diarrhea and they times more than to those having separated drinking water were times in the risk of having diarrhea compare to storage. 56

4 Table 2: Relationship between the socio-demographic factors of caregivers and diarrheal disease occurrence among under-five children (n =245) Diarrheal disease occurrence (%) Socio-demographic factors Yes No Crude OR Age (yrs) % 61% % 28% Gender Male 0.4% 2% Female 10% 87.6% Relation Mother 8.2% 82.44% Other 2.4% 6.93% Education Illiterate 8.2% 61.2% Literate % Occupation House wife 4.5% 71% Workers 6.2% 18.2% Family Income > dollar 9.76% 79.2% >250 dollar 0.81% 10.2% Time given for child care (hrs) < 8 hours 6% 12.6% >16 hours 4.8% 76.6% Table 3: Relationship between the child factors and diarrheal disease occurrence (n=245) Diarrheal disease occurrence (%) Child factors Yes No Crude OR Age of children Less than 1-2 years 10.6% 73% years 0.4% 16 % Milk during first six month Others (not exclusive) 6.5% 29% Mother/Human milk (exclusive) 4% 60.4% Colostrums Yes 2.4% 47% No 8.2% 42.4% Table 4: Relationship between environmental and sanitation factors and diarrheal disease occurrence (n=245) Diarrheal disease occurrence (%) Environmental and Sanitation factors Yes No Crude OR Home Unhygienic 8.5% 57.5% Hygienic 2% 32% Latrine Yes 3.3% 28.5% No 7.3% 60.8% Separated drinking water storage Yes 2.9% 29% No 7.7% 60.4% DISCUSSION (8.2%) of these care givers were illiterate, (2.04%) primary school and (0.4%) secondary The results revealed that the prevalence of diarrhea school, (4.5%) of the care givers were house in under-five children was 11% (26 out of 245). wives, (3.7%) employee and (2.45%) was self employed. The care givers of these children with diarrhea mostly (4.5%) of the diseased children were from low income (10.2%) were female and of them were mothers, 1.6% families. Siblings and 0.4% grandmother. The age of these care (10.2%) of the children with diarrhea were 2 years and givers mostly (6.1%) was between 25-35, (2.45%) was less than, (6.5%) 0f the children with diarrhea were given between 15-24, (1.23%) was and (0.8%) between a bottle feeding, only (4.1%) children was given Breast milk. (8.6%) of the children with diarrhea were living in 57

5 unhygienic homes. (7.6%) had no these separated storages they same one on both drinking and domestic use water. This study revealed that the age of caregivers/mothers between have association with occurrence of diarrheal diseases among children under five years of age (OR ), another study made by Kung u WN, Musau PM, Ochieng A, et al. younger age of caregiver/mother was associated with more diarrhea occurrence (OR 1.665) [14]. Caregivers who are not mothers of the children have association with occurrence of diarrheal diseases (OR ). The education level of the care givers have association with the occurrence of diarrheal diseases, Illiterate caregivers/mothers have association with occurrence of diarrheal diseases among children under five years of age (OR ), another study made by Karki T, Srivanichakorn S, Chompikul J. states that Lower education level of mothers is associated with more diarrhea (2.68) [15] Caregivers who are workers who do not give enough time of caring their children had association with occurrence of diarrheal diseases (OR ). Low family income per month had association with occurrence of diarrheal diseases (OR ) an other study made by Vaahtera M, Kulmala T, Maleta K, et al. in Malawi states that low economic status that has been significantly associated with diarrhea occurrence (1.428) [16]. Children in the age group between 1-2 years had association with occurrence of diarrheal diseases (OR ). Children who received other milk during the first six months of life (bottle feeding) had association with occurrence of diarrheal diseases (OR ), another study made by Yoon PW, Black RE, Moulton LH, et al. in Philibine states that lack of breast feeding associated with occurrence of diarrheal diseases (2.563) [17]. Similarly Children who didn t receive colostrums milk had association with occurrence of diarrheal diseases (OR ). Children living in unhygienic conditions had more association with occurrence of diarrheal diseases (OR ). Those who have no latrines had association with occurrence of diarrheal diseases (OR ). Similarly those who have no separated drinking water storage had association with occurrence of diarrheal diseases (OR ). on the other hand similar researches made in Nepal states that Drinking water stored in unhygienic containers had a relation with the occurrence diarrheal diseases (OR 2.53), similarly Unhygienic houses had that relation (OR 2.12) [18]. Recommendations: Importantly mothers and caregivers should adhere to nutrition and hygiene promotions programmes and give priority to exclusive breastfeeding, safe disposal of faecal material and the adequate washing of hands before breastfeeding and after contact with adult and child stools. It would be much worthy for mothers to form support groups to share information about breast feeding and use of health information especially on the practice of hygiene behaviours. During an attack, mothers who visit health facilities should be taught about the preparation and use of ORS or its substitutes like, lemon- sugar-salt beverage, weak tea etc. at home as a way treating children having diarrhoea. Recognize the signs of dehydration and take the child to a health-care provider for ORS or intravenous electrolyte solution, as well as familiarize themselves with other symptoms requiring medical treatment (e.g., bloody diarrhoea). Separation of drinking and domestic use water is better to prevent contamination of drinking water and the spread of the diseases. Majority of caregivers still have false belief like teeth eruption can cause diarrhea and medicine should be used to get better from diarrhea early. Bosaso district health office (DHO) and all the health workers should give priority to disseminate these statements positively as an important health message to the community. ACKNOWLEDGEMENT This study was kindly funded by WHO/TDR under Short-term training grants for research capacity strengthening and knowledge management, under Impact Grant No We also thank to the Center of Research Training and Development under East Africa University grant Number EAU/110/3 who partially contributed to this project. REFERENCES 1. Mengistie, B., Y. Berhane and A. Worku, Prevalence of diarrhea and associated risk factors among children under five years of age in eastern Ethiopia: A cross sectional study. Open Journal of Preventive Medicine, 3:

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